Friday, July 31, 2015

In a prior posting, the Disease Management Care Blog was reminded that the U.S. health care system is exceptionally complex and non-linear. Thanks to its many overlapping, contradictory, shifting and often non-medical inputs, it defies the simple logic of a single-cause-leading-to-a-single-effect. If economics is the dismal science, health care economics is its dubious spawn.

In this study, the authors examined 10 years' worth of insurance claims for advanced imaging MRI and CAT scans from two multi-state commercial insurance plans and another smaller single state plan. These data were then pooled with a 5% national random sample of imaging claims from Medicare beneficiaries. The authors also interviewed radiologists, health administrators, radiology benefit managers and physician recruiters.

The results? From 2000 through 2005, CT scans grew at a whopping rate of 14.3% but then slowed to 1.4%. MRI slowed in the same periods from 14% to 2.6%. At the same time, starting salaries for radiology specialist physicians significantly declined.

What happened? According to the authors:

1. An industry sprung up. In another example of the adage that "need is the mother of invention," companies that prior authorize imaging studies for medical necessity (for example) were hired by many commercial insurers. They had an impact.

2. Skin in the game. Deductibles, co-insurance and co-pays made consumers think twice about agreeing to a study that was going to result in some out-of-pocket spending.

3. Unilaterally imposed fee reductions. Medicare cut the amount it paid for CAT and MRI studies performed in freestanding centers and physicians' offices. Hospitals were left untouched.

4. Glow in the dark. Media reports on the amount of radiation prompted patients to worry about the long term impact of all those x-rays.

In other words, there was no single lever. Instead, the reduction of high utilization of pricey imaging was due to the confluence of at least four mutually reinforcing trends.

As further evidence of the overlapping trends that extended beyond simple cause-and-effect, Medicare never relied on prior authorization, didn't alter the out of pocket testing expenses for beneficiaries and left the payments for hospital-based imaging untouched. Yet Medicare saw an across-the-board reduction. MRIs don't involve ionizing radiation (they use relatively harmless magnets), but their overall rate went down in concert with CAT scans..

The obvious implication for the population health management service companies is that if they're going to have a significant impact, the likelihood of a successful outcome is far greater if it is implemented concurrently with other supportive interventions.

Barbara Schneider and her team work with Philadelphia health insurer Keystone First's community outreach and care coordination programs to intervene on the "sickest of the sickest" diabetics. These are 35 patients who are admitted on average more than twice a month. Patients who are on a first-name basis with all the local emergency rooms nurses on all the shifts. Patients who live in run-down boarding houses on a good day. Patients who are lucky if their blood sugar is only 600 mg%. We're talking hundreds of thousands of dollars in health care costs.

Dr. Schneider's lay community health workers (more info on the science here) are seeing these individuals in parking lots, McDonald's, row homes and halfway houses to cajole, coach, text, call, shuttle and haggle with patients, families, social workers, pharmacists and insurers to dismantle barriers one patient at a time. If a patient isn't ready to stop abusing drugs, that doesn't mean he can't be taught to use a glucose meter. While living circumstances may be chaotic, that doesn't mean she can't use a cell phone instead of just going to the emergency room.

While Keystone has yet to release an analysis on the impact on claims expense for these patients, a cursory review of the data shows emergency room visits have been cut by a third, while inpatient stays declined by more than half. Even with the DMCB's limited background in analytics, it suspects that when the return on investment is finalized, Keystone will conclude that the program was an unqualified success.

To the DMCB, this is what it's all about. Washington DC can continue its partisan scorched earth battles while, in the meantime, small regional community minded health insurers like Keystone First are figuring out how to do right by patients using novel programs like this.

The authors point out that while blood pressure should be less than 140/90, LDL cholesterol less than 100 in persons with a history of heart attack and A1c should be less than 7% in persons with diabetes, it's clear that the cure can be more costly than the disease.

As a result, they call for measuring and rewarding quality based on accountable prescribing that not only measures the numbers (blood pressure, blood cholesterol or diabetes control), but the percent of individuals receiving conservative or first line treatments. While this approach would require an even more detailed databases/registries, it's within reach of most commercial insurers and advanced electronic record systems. We owe it to our patients to provide a tailored, bottom-up, nuanced and Ver. 2. approach to measuring health care quality.

It's also a concept that the population health and care management service providers could, with the right kind of clinical partners, lead. This calls for a pilot program and, in the DMCB's humble opinion, the sooner, the better.

If you are distressed by the United States' decline, doubt American exceptionalism, share in the angst infecting the progressivist salons and enjoy Aaron Sorkin's tightly written diatribes, you're probably already aware of (or even forwarded an email link to) this angry rant by the lead Jeff Daniels character in the HBO series "The Newsroom."

Unable to resist, the inspired Disease Management Care Blog tapped Xtranormal to imagine a Newsroom-esque angry rant over the widely accepted notion that U.S. health care is so awfully broken.

While there's a lot of management jargon, the author makes a good point about health reform's four necessities. Any health technology provider, clinical enterprise, population health vendor, pharma company, health insurer, research outfit or government entity that can solve just one will have our collective gratitude.

1) Millions of new Medicaid enrollees who are struggling with the twin burdens of poor health status and socioeconomic challenges. If there is a clinical-technology platform that can provide care for this population, now is the time for it to step forward.

2) An influx of healthy millennials who, instead of having "needs" (that was their grandparents' problem) or "desires" (that was their parents' problem), have expectations that they believe can be significantly met with their handhelds.

3) Tens of millions of chronically ill persons who need to have a higher value medical home model scaled up, while we find even better industrial-based approaches to get them to self-manage. At home.

4) High deductibles: if we can get money out of a checking account in Idaho while visiting Istanbul, there's got to be a way to minimize the disparate impact of high out of pocket expenses with increased transparency, value-based purchasing, tax sheltered accounts and other cloud-based financial tools.

Tuesday, July 28, 2015

Whenever the Population Health Blog heard the "value-not-volume" health policy operatives drone on about "provider alignment of incentives," it wondered.... really wondered.... if this Kool-Aid had completely convinced the ACO Adminosphere's inhabitants that their physicians' loyalty to their profession could be superseded by loyalty to their employer.

Sure, running a private-practice sucks and Obamacare's economics favor consolidation, but that's not necessarily enough to capture hearts and minds. The PHB recently heard a local ACO executive explain that her long-employed physicians were still (yes, still) challenged with EHR implementation, teaming, shared savings, quality metrics, practice management, joint ventures and the role of patient educators.

Three states (Maine, Arizona and New York) in the 2000-2005 time frame increased Medicaid eligibility to mostly include childless adults meeting a variety of poverty thresholds. The authors compared changes ("pre-post") in publicly available death rates and health status statistics in these "intervention" states to neighboring states that acted as quasi-experimental "controls (New Hampshire for Maine, Nevada and New Mexico for Arizona and Pennsylvania for New York).

Over time, new Medicaid enrollees were slightly older (40.6 years vs. the average of 40 years), more likely to be male (57% vs. 49% in the general population), nonwhite (27% vs. 20%) and in fair or poor health (20% vs. 11%).

What was interesting was that the authors compared the county-level changes in mortality for the entire state population, not just Medicaid enrollees. Using standard statistical methods to account for baseline differences, the authors found that adjusted all-cause mortality for the intervention states declined by 19.6 per 100,000 versus the control states. Since it takes time for Medicaid enrollment to actually increase after a change in eligibility, the authors also examined the impact over time. They found a strong statistically significant correlation between growing Medicaid enrollment and mortality.

Medicaid expansion was also associated with decreases in rates of patient surveys showing that there was "delayed care" and increases in self-reported excellent or good health status.

The obvious conclusion of the study was that expanding Medicaid eligibility allows persons who are otherwise without insurance to access the health system and receive care for conditions that would otherwise kill them. The DMCB finds the results convincing and should inform the debate in some states about the life-saving merits of expanding Medicaid.

Critics could quibble that unknown factors not captured by the study could have accounted for the observed differences (did pumping more Medicaid money into the system enrich hospitals, enabling them to provide a higher level of care?) and that association does not prove causality (could booming state economies lead to a healthier population, while a generous Medicaid expansion had nothing to do with it?).

DMCB questions:

1) This study doesn't compare Medicaid insurance vs. commercial insurance. If there were a way to use the commercial markets (for example, vouchers), would patients far better? There is research that suggests the answer could be yes.

2. A cruel but important question: how much did it cost? Expanding Medicaid did not save money, it cost and it would be interesting to know the cost per person, per person-year or per quality adjusted life year.

Friday, July 24, 2015

Have you been stymied by health care's complexity? Are you unable to find that one intervention that predictably leads to a desired outcome? Are your best laid plans being upended by countervailing poverty and undereducation? Do you want to make a big splash that portrays your health care chops?

The Disease Management Care Blog says "No problem!" because the fix is simple:

Don't get the DMCB wrong. $150 million will save many lives, but the idea that HIV transmission will be completely halted in 2015 seems fantastical, naive and a little dishonest. Contrast that with William Bennett's reframing the "War On Drugs" with a more honest stretch goal of a "50%" reduction in U.S. drug abuse. It didn't end well, but give the guy credit for telling it like it is.

The DMCB's conclusions:

1. Beware politicians with little reality-tested experience taking advantage of our desire for easy answers wrapped in short catchphrases. While our aspirations should exceed our reach, the DMCB cautions that we need to be on the lookout for health policy hope being undercut by hype.

2. Ms. Clinton's political skills are considerable. The DMCB finds it unlikely this political impresario will simply fade away.

3. This false god of health care perfection summed up with easy answers may be one of the reasons why all those local QI programs aim for "100% HEDIS compliance" and "zero" hospital readmissions. Who can blame them when our political class is leading the way?

The DMCB felt so strongly about this, it proposes it's own motto: "Be motto free with the DMCB."

The authors used the ongoing Gallup-Healthways survey that questions representative samples of the U.S. population about their health insurance status. Since it began, this repeat survey has assessed changes in the coverage of adults 18 to 64 years of age. The authors used these data to assess the trends in insurance status that were associated with the roll-out of Obamacare between January 2015 to June 2015.

For all of 2015 and the first part of 2015, the nation's uninsured rate was 20% to 21%. Following the star-crossed open enrollment period that began in the fall of 2015, the uninsured rate began to drop. By April of 2015, it fell to 16.3%.

Read these headlines assembled by Kaiser Health News and it's easy to get the impression that America's physicians believe everyone else is to blame for health care costs. A cursory read of the underlying original research suggests otherwise. Regardless of the interpretation, the results should give pause to anyone who thinks health care reform is a slam dunk.

The Disease Management Care Blog explains.

3900 practicing physicians were randomly selected from the AMA Physician Masterfile. Three physicians were outside the U.S., leaving 3897 docs who were mailed an 8-page survey. $20 was used to increase the response rate. Non-respondents were mailed a second and then a third follow-up. The ultimate response rate was 65% and, aside from a one year age difference, the respondents were quite similar to the original 3897. The survey that was used can be found here.

The results are nicely summarized in Table 3 (go to this link, click the "Tables" tab).

99%, 97%, 94% and 86% of the respondents felt hospitals/health systems, health insurers, pharma and trial lawyers had "potential" major or some responsibility, respectively, to lower health care costs. 95% and 98% also felt the same was true for physicians and patients, respectively.

The DMCB take: None of the answers were mutually exclusive. The physician-respondents thought everyone was responsible. That being said, if you look at Table 3, you'll see a spread of "major" vs. "some" responsibility. Physicians were less likely to assign "major" responsibility to themselves (prompting the headlines above) but that's because docs believe their job is to advocate for their patients regardless of cost.

Similarly high percentages of respondents generally felt that continuity of care (98%), chronic disease care coordination (98%) and reducing fraud (93%) were important means of reducing costs. What was interesting that fewer felt the same about the electronic health records (74%), penalizing docs for readmissions (41%) or bundling payments (35%). They were also less sanguine about increasing patient "skin in the game" with higher co-pays (61%) or high deductibles (58%).

The DMCB take: More physicians believed in the cost-reducing potential of disease management/care coordination than the EHR. While part of the respondents' skepticism about the economic incentives that underlie much of health care reform is arguably motivated by self-interest, the DMCB suspects physicians also genuinely believe patient needs trump economic penalties. Regardless of the underlying thinking, the results should give pause to policymakers and politicians who believe that readmission penalties and bundled payments are a no-brainer and that docs have bought-in.

The DMCB will close with the following scenario:

Pretend you are a Vice President for Medical Affairs, or a Chief of Staff, or a health system CEO about to announce a major collaboration with a major health insurer like CMS or a Blues Plan. You've done your homework, read the journals, listened to the experts and anticipated the future. You haven't been a regular reader of the DMCB.

You've called a meeting of the physician staff - the professionals you are counting on, caring for all those patients - and your job is go to the front of the auditorium and convince them that the success of your new venture relies on lowering health care costs with new payment arrangements that align incentives, in tandem with the launch of an electronic health record.

If the survey outlined above is even partially true, would you want to be that VP, Chief or CEO?

Thursday, July 23, 2015

Don't be. While the Disease Management Care Blog prays for the victims and families of the Aurora shooting and hopes that Penn State's travails leads to greater protection of innocents, the DMCB is also an optimist. Humans are remarkably resilient. We rise above evil, We learn from mistakes. And then we carry on.

It'd also be tempting to let the last 72 hours cast a pall over the other Big Problems that beset us, including our sputtering economy, persistent unemployment and politicians who seem unequal to the task at hand. But if you're looking for a better spin on things, a recent The Economist editorial on the Comback Kid paints a different picture. American debt is being pared, family homes are now beginning to look like bargains, the banks are shedding bad loans, a weaker dollar and a nimble private sector (including the "app" factories of Silicon Valley) are driving U.S. exports up and natural gas is making energy cheap and plentiful. Oil imports are down and the U.S. is becoming a net exporter of hydrocarbons.

What's more, says the DMCB, the U.S. population birth rates and immigration levels are pointing to a 'sustainable demographic dividend,' while our universities remain the envy of the world. Assuming our politicians figure out a way to cut spending, increase revenue and keep inflation at bay without doing more harm, the longer term fundamentals are decidedly a cause for optimism. That's a big "if," but it could happen.

But if you think a another reason for economic optimism is the simple expansion of the health care industry, Drs. Baicker and Chandra, writing in the New England Journal about The Health Care Jobs Fallacy suggest you think again. While politicians may like the prospect of the medical-industrial complex hiring lots of voters who pay lots of taxes, every dollar spent on patients is one less dollar spent by society on education, infrastructure, food, shelter, retirement savings and other government services. In addition, those dollars are not necessarily associated with meaningful gains in life quality or expectancy. And while it could argued that "reforms" will ultimately reduce costs, it's possible that improved productivity combined with more persons with insurance will ultimately drive demand up.

Which raises a good point.

The economy may turn the corner sooner than we expect, and its long term prospects - despite our political class - are good. In that setting, health care companies that run counter to the usual historical business cost-plus model by driving higher quality and lower costs will succeed. Those will be the enterprises that attract customers that can increasingly afford their services. It'll be interesting to see how ACOs, population health companies, the PCMH and wellness offerings fare.

According to this The Hill article, President Obama took a break from tackling red lines, gun control, immigration reform, Trayvon Martin, the economy to make an appearance at a July 22 Obamacare promotion-planning meeting that included a host of A-list celebrities. They'll be needed to convince the young invincibles to pony up hundreds of dollars for health insurance that they don't want.

Despite the DMCB spouse's unflattering assessment of her husband's media chops, the Disease Management Care Blog thinks it should have been in that White House room.

It has a lot to contribute.

For example, American Idol finalist Jennifer Hudson was there. How about a new CMS-sponsored talent show, says the DMCB, that is hosted by Ms. Hudson, called American Muddle? Enter the early crooning favorite, Hope Igeddadok, singing a reprise of that Dire Straits hit, "Money for Nothing."

And what about Improv comedy artist Amy Poehler? After a great stint at SLN, she went on to star in the hit comedy show, Parks andRecreation. The DMCB suggests a pro-Obamacare commercial that features Deadlock and MakeItUpAsWeGoAlongination.

Alicia Keys was there and can she sing! She can be this "Girl Is On Hire" for Obamacare in an MTV video-advert.

And it was no accident that Bon Jovi's people were there, what with a song list that includes "Livin' on a Payor," "Panel Says Dead or Alive," "It's My Right," "You Give Hope a Bad Name," "Runaway Costs," "Bad Medicine" and "Shot Through the Heart and We'll Still Pay."

Last but not least, folks must have been excited about Will Ferrell. Since his Bush impersonation has run its course, Ron Burgundy may be the best choice for some faux-news insights. He can provide periodic updates on how the health insurance exchanges are going: "They've done studies you know," "Sixty percent of the time it works every time," "In a glass case of emotion," and "Stay classy, Obamacare."

If anyone in the White House is reading this, just drop an email. The DMCB is ready to roll up its sleeves and help.

Patients' intake into the program was initiated with a face-to face meeting with a nurse care manager. After a physician-approved care plan was in place, the patients were telephoned and engaged in the protocol. The patients could then use a voice-activated system or a website to report disease status. Outbound nurse calls were prompted if the patients requested it, reported a problem, didn't have adequate disease control, if the medications were not being taken as prescribed or if there were side effects. After 12 months, patients in the care management program, compared to a control group, had clinically and statistically significant improvements in the control of their condition .To the Population Health Blog, this narrative has been repeated dozens of times involving numerous chronic health conditions. In this latest example, Dr. Kroeknke and colleagues randomly allocated 250 patients with three months or more of chronic musculoskeletal pain to either a) state-of-the-art pain care or b) state-of-the-art pain care plus nurse led care management.

Twelve months later (and after only one drop-out), patients in the first group rated their pain as having dropped from a baseline of 5.1 to 4.6 out of ten (zero is no pain, 10 is awful), while the second care management group rated their pain as having dropped from 5.3 to 3.6. Total time spent by the care manager averaged 3-4 hours per patient.

While patients in the care management group were taking more medications, there was no difference between the two groups in narcotic use. There was also no difference in health care utilization.

The PHB's take:

While the authors credited the care plans that triggered increases in medications that were tailored to patient preferences, the PHB wonders if a greater sense of control combined with the perceived support of a sympathetic listener also contributed to the greater improvement in pain.

Once again, there wasn't hard "savings" or a "return on investment." However, the expense of only three to four hours of nurse care manager time to achieve a one-point improvement on a 0-10 scale of pain not only seems like a wise investment, it's a comparative bargain.

"'Blue Cross’ Patient-Centered Medical Home is transforming health care delivery, saving millions of dollars and improving lives,' said Daniel J. Loepp, president and CEO of Blue Cross Blue Shield of Michigan."HIT Consultant's insightful coverage of healthcare innovation said:"According to the analysis, 'Partial and Incremental PCMH Practice Transformation: Implications for Quality and Costs,' researchers found that its Patient Centered Medical Home model, when fully implemented, resulted in:

3.5 percent higher quality measure

5.1 percent higher preventive care measure

$26.37 lower per member per month medical cost for adults"

"Whoa!" said the Disease Management Care Blog. Since $155 million from $300 per member per year reductions in claims expense is some very serious savings that, until now, has never been reported for the PCMH, it naturally looked at the original research.

What did the sleuthful DMCB find?

Contrary to flattering press releases quoted above, the Blue Cross Blue Shield of Michigan did NOT conclusively save any money. The observed savings of $26.37 PMPM failed to achieve statistical significance and could have been the result of normal random variation that naturally occurs in the flow of claims payments.

The DMCB explains.

Physicians participating in the Blue Cross Blue Shield of Michigan Physician Group Incentive Program (PGIP) were in two payment tiers: 1) "partial reimbursement" for self-reported PCMH implementation and 2) 10% "fee enhancements" for self-reported "significant" PCMH implementation. As the DMCB understands it, 65% of all the PCPs in Michigan participated in the self-reporting in both June 2009 and June 2010. These docs cared for approximately 1.5 million Blue Cross Blue Shield patients.

During the course of self reporting, docs had to attest to the presence of PCMH capabilities, including use of a registry, obtaining performance measures, care management capabilities, patient self-management support, 24-7 patient access, test tracking and follow-up, e-prescribing, a web portal, specialty referral guidelines, preventive services and linkages to community services. Various domains within each of the capabilities were assigned a weight that was rolled into an overall score: the higher the score, the "more" the PCMH.

The researchers examined the claims history for the patients cared for at a total of 1,787 practices that were in the PGIP, had a minimum number of BCBS enrollees, had no missing data and were not quality outliers. Their median enrollment was 303 members and a mean per member per month (PMPM) claims expense of $311.

Compared to practices that never achieved any PCMH capabilities, the PMPM for practices that attained "full" (i.e. significant) PCMH implementation was, compared to practices that never achieved any PCMH implementation, $26.37 lower for adults.

The p value for the $26.37 quoted on page 15 of the manuscript equaled 0.0529.

For children, the PCMH was associated with a $7.45 increase in costs. That likewise failed to achieve statistical significance (p = .096).

No where in the manuscript do the authors claim there were "155 million" in savings. The DMCB suspects the authors of the press releases extrapolated the statistically non-significant figure of $26.37 to a population count. Garbage in, garbage out.

The DMCB take:

1. Its highly likely that BCBS of Michigan has additional actuarial figures that support the cost effectiveness of the PCMH. BCBS of Michigan also put its numbers into the public domain. It's also likely that that PGIP and the PCMH represents an important opportunity to build and collaborate with a vibrant primary care network, which ultimately transcends any monetary savings. Kudos at many levels to BCBS of Michigan, says the DMCB, despite an over-generous misinterpretation of published health services research.

2. While the DMCB did not report on the quality measures that were concurrently reported in this HSR study, it also appears statistically significant quality of care gains were made. That means there were increases in quality with no increase in cost. That's good news and, thinks the DMCB, a more honest appraisal of the outcomes.

3. Unfortunately, BCBS of Michigan did not report the "net savings." As noted above, providers were paid to implement the PCMH, which represents an additional and "hidden" PCMH cost. Assuming the $155 million in reduced claims expense is real, it would have to be contrasted with the millions in additional fees that were paid to the doctors.

These weenie changes can add up to additional ad revenue. Ditto for the techy Google's search, Amazon's placements and Facebook's ads which, according to Schumpeter, are getting a return on investment from "every pixel" of the monitor screen you're using to read this blog.

Unfortunately, says The Economist, this big data approach has been more difficult for the for the traditional "bricks and mortar" businesses, which have traditionally been fixated on traditional accounting measures. But, as these businesses tether their infrastructure increasingly to information technology, they're getting there: UPS is monitoring 60,000 delivery vans, retailers are assessing how in-store placements generate the most revenue and businesses are measuring how the mix of different types of employees relates to productivity.

The PHB would rate most health care providers as being in the bricks and mortar category than in the technology space. They have a way to go.

Two lessons:

1) Big data doesn't replace traditional business monitoring of revenue and expense, balance sheets, averages and standard deviations, it adds to it. And yes, that ceaseless tinkering adds cost that - in the right hands - should have a return on investment.

2) The "tinkering" has its share of failures in addition to successes. While The Economist can point to some wins, the landscape is probably littered with losses.

Saturday, July 18, 2015

And when a policy maker, speaker, expert or consultant sagely points out that the U.S. doesn't really have a health care "system," what does that mean?

According to Lewis Lipsitz writing in JAMA, "complex" means that the system is made of multiple components that interact non-linearly (for example, they can be self-reinforcing) and over multiple scales (such as patient, family, hospital and government) that can lead to unpredictable results. The good news is that this complexity can lead to outcomes that are greater than the sum of its parts. Unfortunately, the bad news is simple payment levers or single disease protocols can lead to unintended consequences.

Dr. Lipsitz's insight for Disease Management Care Blog readers is that complex systems can engage in emergent self-organized behaviors with the guidance of a "master plan" that harmonizes aims, limits and resources. For example, U.S. agriculture evolved from a highly inefficient enterprise into a very efficient farming system. All it took was some multi-stakeholder experimenting, measuring, learning and feedback. Think the flocking of birds, the synchronized flashing of fireflies or the DMCB spouse, her sister and mother-in-law ganging up in criticizing the DMCB's admiration for vampire vixen movies.

That's why, when the Affordable Care Act is viewed through the prism of complex systems theory, the author optimistically believes we may be on the verge of a transformation of U.S. health care. By promoting aims, imposing some limits and using some incentives through the use of a variety of risk sharing mechanisms (for example, episodes of care, upside risk sharing), it's possible that self-organized behaviors will emerge and "move the needle" in the right direction.

What doesn't work are specific and narrow single-purpose interventions. Dr. Lipsitz points to the infamous "three day rule," which prohibits admission of a Medicare beneficiary to a skilled nursing facility (i.e. a nursing home) unless the patient has first spent at least 72 hours in a hospital. While intended to reserve nursing home admissions for patients who really need it, what happened in the complex system was an increase in unnecessary inpatient admissions just so patients can achieve criteria for coverage of a nursing home stay. DMCB readers are familiar with other examples, including tight diabetes control (leading to the apparent death of some persons with diabetes) and the timely administration of antibiotics to ER patients with pneumonia (that resulted, it turns out, unnecessary antibiotics in persons who turned out to not have pneumonia)

Which suggests that the U.S. does have a health care system, it's just that its complexity defies the narrow, parochial and linear expectations of all those experts, speakers and consultants (except one, by the way).

The lesson for the population health management community is that we need to be aware of this notion of complexity and include "self-organizing behaviors" as an additional dimension as interventions are developed.

Ah, summer and its long hazy days of liquid sunshine. The Disease Management Care Blog doesn't like it either, but may change its mind after reading Louise Norris' "Midsummer Wonk's Dream" edition of the Health Wonk Review at the Colorado Health Insurance Insider. Louise's summer-ies of the latest wonkery is well worth a read.

Friday, July 17, 2015

From time to time the Disease Management Care Blog receives submissions from readers. M'Lynda Owens is a registered nurse with a research interest in population health as well as the provider and payer dimensions of the Medicaid program.

Governing.com has posted an interactive state-by-state analysis of the expected impact of ACA. It’s worth taking a look at the map. The number of uninsured in these states ranges from just over 500,000 to 5.8 million, while the percentage of potentially eligible uninsureds ranges from 43% to 63%.

Since many of the states that are opposing an expansion of Medicaid also have the high rates of poverty, obesity, diabetes, and uninsured adults, how could anyone is it believe that this decision is in the public interest? The likely outcome of this venal "opt-out" decision is that all the citizens of these states will have to bear an even greater portion of the burden of the states' responsibility for the working poor, but not in a straightforward fashion. Rather, this burden will take the form of hidden taxes and additional strains on public wellbeing in other sectors such as infrastructure.

The good news is that the uninsured appear to have a strong ally in their states' hospitals. Uncompensated care cost hospitals nationwide a combined $39.1 billion in 2009, according to estimates from the American Hospital Association. According to the website, governing.com, the Texas Hospital Association worries that its members will be forced to pick up the tab for those lacking insurance. One spokesperson stated “Texas hospitals recognize there are concerns with expanding the Medicaid population, but given the state’s high number of uninsured, all options for gaining insurance coverage must be closely considered.” He also said “Without the Medicaid expansion, many will remain uninsured, shifting costs to the insured and increasing uncompensated care to health-care providers.”

These states' governors likely expect that their ongoing attempts to disenfranchise the working poor will be politically popular with voters in the upcoming fall elections. It will be interesting to watch whether the hospitals and their allies, the physicians, will prevail and convince their states' politicians to opt into the Medicaid program and take the money.

If that happens, it'll be because the Governors were persuaded to make the right decision for the wrong reasons.

Like President Obama's search for the precise rhetoric that can finally turn Republican obstructionism into cooperation, as well as Governor Christie's search for the one cure that turns girth into svelteness, electronic health record (EHR) advocates keep looking for that one EHR study that proves that their financial black holes are really sources of profitability.

Alas, it came away disappointed. EHRs have yet to consistently "save money."

The DMCB explains.

The Massachusetts eHealth Collaborative (MAeHC) has been promoting the community-based installation of EHRs since 2006. 32 Bay State communities applied for their assistance. Three were selected. Thanks to MAeHAC, by January 2008, 167 outpatient physician clinics (86% of the total in these communities) were outfitted with one of several commercially available EHRs.

The cost to MAeHC was a whopping $130,822 per provider.

Realizing a "natural experiment" outcomes study could be fashioned, considerable demographic analytics and statistical effort was used to identify which non-EHR communities most closely resembled the three winners described above. Six communities were selected as comparisons. Two (unnamed) commercial health insurers provided claims data for the patients in the three EHR communities and the six best-matched non-EHR communities.

Keep in mind that the health care system has an ongoing background rate of cost inflation. In this study, the baseline period ran from January 2005 to March 2006 (before the EHRs were installed anywhere), while the EHR-live period ran from January 2008 to June 2009. This allowed the researchers to compare the two community groups' increases in health care claims expenses compared to baseline once the EHR went live.

After looking at more than 4.8 million patient-months worth of data, the researchers found:

Total health care costs increased over baseline by .78% in the EHR communities vs. 1.09% in the non-EHR communties. This .31% difference was not only small, it failed to achieve statistical significance.

The per member per month (PMPM) costs went from $151 to $173 ($22 increase) in the EHR communities vs. going from $155 to $179 ($24 increase) in the non-EHR communities. Once again, tests of statistical significant indicated these small shifts could have been the result of randomness.

When categories of health care utilization were examined, there was no meaningful impact on inpatient or pharmacy utilization. The two pieces of good news were that a) the trend for ambulatory (or outpatient) favored the EHR communities (.41% baseline to 1.12%) vs. the non-EHR communities (.14% baseline to 1.2%), and b) the trend for radiology studies favored the EHR communities (1.03% baseline to .6%) vs. non-EHR communities (-.25% baseline to .94%).

For the 25% of the study population with one or more chronic conditions, there was no impact on total or ambulatory cost trends. Radiology, however, showed a statistically significant shift that favored the EHR.

The authors relied on trend calculations to calculate how the PMPMs would have compared in the intervention vs. control communities. Even though the savings of $5.14 was not statistically significant, the authors projected a 7 year timeline "... to recoup the projected 5 year adoption cost in the (EHR) communities of $130,822 per provider."

The DMCB's take

Despite the pro-EHR spin, this Annals article falls far short of being a study that the medical-technological complex can use to justify its existence. The bottom line is that costs did not drop in statistically significant (p less than .05) or financially significant (a seven year return based on a faux $5 PMPM savings) manner. Let's be honest: there is only one beneficiary of the MAeHC $100K per doc investment, and it's not the patient, the providers, payers or government: it's the vendors that sell these systems to a technology-addled health system with the collusion of too many naïve policymakers.

If ACOs really think their EHR systems are going to be the panacea that helps them tame health care costs, this study tells them that they may be in for a nasty surprise.

But, asks the Disease Management Care Blog, how do we really know that that Hadrosaurus wasn't pretending to be dead when the T rex took its bite? Alternatively, the Hadrosaurus could have been sleeping and only looked dead to a slow-witted and lazy T rex.

Dino doubts, says the DMCB, remain.

Such is the level of skepticism that the DMCB is bringing to its reading of the recent CMS press release describing the initial results of the Pioneer ACO program. CMS says "positive" and "promising." The DMCB says "problematic" wonders if, like the T rex dilemma, there isn't an alternative interpretation.

According to the press release, the health care costs for the 669,000 Medicare beneficiaries cared for by the 32 Pioneer ACO program providers grew only .3% versus .8% for a parallel group of "similar beneficiaries." 13 organizations exceeded the savings threshold, which will lead to Uncle Sam writing checks for $76 million in shared savings.

This front page article in The Wall Street Journal has more detail. It says 18 of the 32 reduced health care costs, which leads the DMCB to conclude that five otherwise "successful" participants did not cross the required savings threshold. Two participants lost money. That, in turn, suggests the remainder, or twelve, broke even.

Details on how each individual institution fared are not readily available. According to WSJ, Boston's Partners Healthcare reduced Medicare claims expense by $14 million. They will be rewarded with a shared savings check of $7 million. Wisconsin's Bellin-ThedaCare will get "several million."

Good "win-win" news for the Pioneer organizations, CMS, Uncle Sam and U.S. taxpayers, right? A critical mass (40%) achieved millions in shared savings, which means proof of concept met and that a key part of Obamacare is successful, right?

In addition, it's possible that for some of the 13 "winners" that the shared savings awards won't match their up-front multi-million dollar investment either. Assuming that's true, it's possible that as many as two thirds of the Pioneer organizations lost money. No wonder 9 of the participants have signaled a desire to exit the program.

The DMCB's dinosaur analogy may be apt. Given a two out of three likelihood of losing millions in the first year of operations, ACOs may just be too big and complicated to survive in the current health care environment. Nonetheless, the Pioneer program will continue and the DMCB will stay tuned for the Year 2 results.

In the meantime, the DMCB wishes CMS good luck in using these "positive" and "promising" results to expand the program anytime in the near - or distant - future.

In its early health services research career, the DMCB's studies consisted of creating study protocols that included data collection and storage, very high end computing, statistical planning and a carefully contrived reporting format. The timeline typically spanned over several months, required high end computing, involved fussy Ph.D. level statisticians unaccustomed to exceeding customer expectations and ultimately having to convince a narrow, highly educated, and skeptical audience of the veracity of the DMCB's conclusions at a scientific meeting.

While that is still necessary in traditionally funded research studies, the story is now far different in mainstream health care and insurance settings. Tapping electronic record or insurance claims data bases are now far easier. Statistical software packages are do-it-yourself and 'walk' users through the basics. Ph.D-level statisticians are unnecessary. Mainstream health workers have a working appreciation of measurement as well as trending and the folks inhabiting the C-suites use their in-house research conclusions in core business planning. And it can all be done using desktops that cost a few hundred bucks.

At the Star Ratings Congress, the DMCB listened to speaker after speaker who presented highly polished insights about quality and cost that were developed thanks to in-house information systems and analytics resources that would have been unthinkable a decade ago. This advance in data management has enabled providers and payers to spot trends on a month-to-month basis, compare local performance to historical as well as national benchmarks and report outcomes to external agencies on a regular basis. The research efficiency was astonishing.

It was also so taken for granted. It shouldn't be. Compared to 10 years ago, the industry has gone from the wheel and fire to the internal combustion engine and automatic transmission.

The DMCB thinks its going to get better too. While the electronic health record vendors have been notoriously inept at supporting data analytics, it's going to just be a matter of time until community-based providers can hit a function key on their keyboards and scan (for example) mammography rates by age, race, zip code and months since last visit. Insurers will be able to project which enrollees with diabetes on three or more prescription drugs are least likely to take their medicines after controlling for co-pay and weather.

When we finally do figure out how to increase quality and reduce costs, it'll be because desktop analytics had finally reached the tipping point.

The article points out that groups like the American Medical Association (AMA) along with the various sister specialty physician organizations, along with health systems, practice associations and various non-governmental entities, are critical to the success of the Affordable Care Act. These doc groups been long-time advocates for health reform, are still trusted by a significant number of providers, collectively represent a majority of docs and bring insights to a complicated health system.

And what are they doing to help with reform? According to the authors, they've been serving as "conveners," helping to marshal resources, are creating standards and helping regulators. While the JAMA article naturally mentions a number of national initiatives (such as Choosing Wisely), the PHB points out the same kind of important activity is occurring at the state level. A good example can be found here.

Before some PHB readers tut-tut the faux importance of the AMA and its many national and local affiliates by having you believe that docs have transitioned their loyalty from their profession to their employers, the PHB would point to three sentinel events that say otherwise:

3. While tort reform has been outside the scope of this blog, an important ballot initiative dealing with California's benchmark Medical Injury Compensation Reform Act (MICRA) will be put before the state's voters this fall. The lead organization of an impressive coalition of labor, business and consumer groups that has been created to defeat the proposition and preserve MICRA is, you guessed it, a state medical association.

The lesson for population health providers? Reach out to and work with the physician groups at all levels of reforming the system.

Wednesday, July 15, 2015

It's an old conservative joke, but what is the one key difference between health insurers and terrorists?

Answer: liberals only occasionally attack terrorists.

For the latest example of the continuing disdain for health insurers, check out this rather typical July 5 Washington Post article "Is this the end of health insurers?" After extolling one enlightened company's decision to self-insure its workers*, writer Sarah Kliff points out that hospitals can cut out the insurer middle man and offer the same service. The result, says the article, will be the wiser use of the premium dollars, lower costs and fewer coverage denials.

The contrarian DMCB thinks they'll continue to stick around because they perform a two useful public services:

1. Keeping Providers From Going Belly Up: There have been too many examples of hospitals and physician organizations being unable to collect today's premium dollars and hold them as a promise to pay for tomorrow's sickness. Whether it's not charging enough or being unable to say no, providers are vulnerable to running out of cash and being unable to cover their insureds' health care bills. The DMCB says it's better to insulate hospitals and doctors from the perils of the underwriting cycle. Insurers do that.

2. Keeping Providers From Going to the Dark Side: Assuming a hospital or physician organization can hold the dollars, pay for all that health care and end the year in the black, there's a good chance that they'll do it by ultimately employing the same tactics used by many mainstream insurers: denials of services based on determinations of "medical necessity."

*As an aside, self-insured companies don't always act in the their employees best interest. Look at this infamous example and note that Cigna only "administered" the insurance plan on behalf of a self insured organization.

Tuesday, July 14, 2015

The Population Health Blog has been practically banished from our living room when the spouse is watching TLC's Say Yes to the Dress. This reality show follows the travails of young brides as they search for that perfect wedding gown while also dealing family expectations, tight budgets and dubious body art.

When the PHB stops in and pauses to watch the bridal drama unfold over more than just a few minutes, it naturally wants to share. Mysteriously, the spouse treats its helpful outreach like some sort of provocation.

Little wonder. Years ago, the PHB medical director learned that the best way to make itself unwelcome at dreary management meetings dealing with the Medicare Advantage STARS Program was to inconveniently offer various insights, such as:

"I hope the groom takes a look at that mom, because if that's what the bride is going to look like years from now, he may want to reconsider.""Seems to me she's trying to fit 50 pounds of potatoes into a 30 pound bag!"

Written to compliment a JAMA research paper on the same topic (reviewed by your Disease Management Care Blog here), this short manuscript uses fawning policy-speak that puts the creation of the PCMH on the same level as the discovery of penicillin and the defeat of managed care.

Knowing that many DMCB readers likewise share in the unquestioning admiration for the PCMH, the DMCB is pleased to offer this compact summary of the JAMA article using handy rhetoric that can be deployed at any time against a skeptical actuary, a cost-cutting Republican or a hell-no-we-won't-pay insurance executive. Simply shake vigorously and spray in the direction of that offending nuisance:

Primary care in the United States is in disrepair. Other countries that have primary care systems based on patient centeredness of the PCMH benefit from higher quality and lower costs. Promising studies of the PCMH have all but proven that it is associated with downstream savings, which should be enough to justify payment. What's more, the concept has been endorsed by the World Health organization and the Institute of Medicine. The PCMH is also at the forefront of value vs. volume payment reform, investing in better health for the nation, overcoming disparities and increasing access to care for vulnerable and underserved populations. That's why Federal government action that builds on the promise of the Affordable Care Act in the form of 1) additional demonstrations, 2) Medicare reimbursement for care coordination and 3) regulation of ACOs to assure incorporation of the PCMH is necessary.

And in the interest of fairness for all the PCMH skeptics, here's what you can say back:

Primary care is simply struggling to demonstrate value to health care consumers who, when given achoice, prefer specialists' care. Other countries' culture, governance and socioeconomics could account for much of their success with primary care and that's why there is no guarantee that simply importing it to the U.S. will prove to be a health care panacea. While there have been multiple PCMH studies, not one (in contrast to other population-based interventions) has demonstrated statistically significant savings, meaning that any observed savings could have been the result of random variation. While endorsement by WHO and the IOM are impressive, Americans have a prickly unwillingness to take large institutions' word for it and this is unlikely to have any impact on patient buy-in. Too many patients and doctors know that the terms "Federal" and "action" are not only contradictory, they confer a faith in government (as well as the ACA) that is not shared by a significant percentage of the very people that are supposed to benefit from the PCMH. Last but not least, looming "Taxmeggedon" makes it improbable that our politicians will embrace the notion of investing today's hard dollars for tomorrow's ephemeral savings. Until multiple studies in multiple settings consistently show savings vs. a valid comparator, the PCMH should remain a topic of research.